Support Grant Application

Please return to: Support Services Team MND Association Office use: PO Box 246, Northampton, NN1 2PR Date received: Tel: 01604 611802 Decision & date: Fax: 01604 638289 Date actioned:

MND SUPPORT GRANT (CARE) APPLICATION FORM

The MND Association cannot use its resources to replace statutory responsibilities. In completing this application form, health and social care professionals should include supporting documentation demonstrating efforts made to secure statutory funding. Funding is limited, so applications will be assessed on the basis of need and impact. In signing this application form the professional confirms every effort has been made to seek statutory and other appropriate funding.

Please email completed form to [email protected] or return to the above address. We will not process incomplete forms. We will contact the person with MND to inform them of the progress of the application. Please include ethnicity according to Department of Health coding.

1. DETAILS OF PERSON WITH MND Full name of person with MND Gender:

Male: Mr/Mrs/Ms/Miss/Dr/Other...... Female: First Name: Surname:

Ethnicity code*: (see appendix A)

Place of diagnosis: Date of birth: (i.e. name of hospital/care centre) Address Date of diagnosis: Contact details (if different): Postcode Name: E-mail Telephone Tel./Email

Motor Neurone Disease Association, 10-15 Notre Dame Mews, Northampton, NN1 2BG Registered Charity no: 294354 2. DETAILS OF PROFESSIONALS

Name of requesting professional Job title

Address Contact name and telephone/e-mail of a colleague who can be contacted if you are unavailable:

Postcode E-mail Telephone

Normal working hours when you can be contacted:

GP’s name and address:

3. DETAILS OF MND SUPPORT GRANT REQUEST

Motor Neurone Disease Association, 10-15 Notre Dame Mews, Northampton, NN1 2BG Registered Charity no: 294354 Has an appropriate health and social care assessment relating to this application taken place? No, please complete prior to submitting application Yes Date: form

Is the person with MND in receipt of any of the following:

 NHS Continuing Health Care funding Yes No  Personal Health Budget Yes No  Disabled Facilities Grant (DFG) Yes No  Any other funding Yes No If yes, please state

Is the person with MND willing to make a financial contribution? one-off per month Yes No How much? ...... Has an application been made to statutory services? Yes No

What provision is available?

Amount of support requested £ (up to a maximum of £1,500 unless exceptional circumstances – please state) Purpose of the support grant:

Reason for MND Support Grant (please attach supporting documentation i.e. quotes) Please include any relevant information that will help us to prioritise the request.

How will this improve quality of life for the person with MND and/or their carer?

Has the person with MND consented to this application? Yes No

Signature of person with MND (Professional can sign on person’s behalf)

4. PAYMENT DETAILS If a contribution from the MND Association is agreed, we will contact relevant person to arrange payment.

5. STATEMENT BY THE REFERRING PROFESSIONAL

Motor Neurone Disease Association, 10-15 Notre Dame Mews, Northampton, NN1 2BG Registered Charity no: 294354 If this application is approved, I understand that, unless otherwise agreed with the support services:  Where appropriate, it is my responsibility to continue to pursue funding from statutory services  It is my responsibility to order equipment or adaptations and liaise with the supplier, where appropriate  It is my responsibility to monitor and assess the ongoing needs of the person with MND in relation to this application.  It is my responsibility to notify suppliers and the MND Association when ongoing funding is no longer needed.  It is my responsibility to notify the relevant statutory service that the MND Association has provided a MND Support Grant to a person with MND  Should I leave my current post, I will notify the MND Association of the name of the professional who has taken on the responsibility for ongoing communication and liaison with the MND Association

Signed: Date:

The MND Association is committed to adhering to the Data Protection Act 1998. We store and occasionally share your information within the Association or with health and social care professionals where it helps with your care or with the development of better services.

We may also contact you from time to time with information about developments in the Association or appeals you may wish to be involved in. If you do not wish this to happen please let us know [email protected]

Appendix A

*Ethnicity Codes

White Asian or Asian British Other Ethnic Groups A British H Indian R Chinese B Irish J Pakistani S Any other ethnic group C Any other White background K Bangladeshi L Any other Asian background

Mixed Black or Black British Other codes D White and Black Caribbean M Caribbean Z Not stated E White and Black African N African 99 Not Known F White and Asian P Any other Black background G Any other mixed background

Note: The national code of 'Z - not stated' means that the person had been asked and had declined, either refusing to provide this information, or a genuine inability to choose. 'Not known' should be used where the patient had not been asked or the patient was not in a condition to be asked.

Motor Neurone Disease Association, 10-15 Notre Dame Mews, Northampton, NN1 2BG Registered Charity no: 294354